DD Form X711 Vietnam War Commemoration Certificate of Honor: In Memor

OMB No. 0704-0500
OMB approval expires

Vietnam War 50th Commemoration Certificate of Honor: In Memory Of
(The In Memory Of certificate is for immediate family members only (parents, siblings, children, spouse) of a veteran who is listed on the
Vietnam Veterans Memorial in Washington, D.C.)
The public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, Alexandria, VA 22350-3100 (0704-0500). Respondents should be aware that notwithstanding any other provision of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO THE EMAIL ADDRESS BELOW.

(FedEx does not deliver to P.O. Boxes)

b. SHIPPING
TELEPHONE NO.
(For FedEx)

Example: Mr. J.Q. Smith, 123 Main Street Apt #, City, State, ZIP

898-123-4567

1.a. NAME AND ADDRESS TO SHIP CERTIFICATE FOR PRESENTATION

Name:

Street:

City:

State:

Name:

Street:

City:

State:

Name:

Street:

City:

State:

Name:

Street:

City:

State:

Name:

Street:

City:

State:

Name:

Street:

City:

State:

Name:

Street:

City:

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Name:

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Name:

Street:

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Name:

Street:

City:

State:

4.a. REQUESTED BY

DD FORM X711, 20160301 DRAFT

2.a. DECEASED
VETERAN'S NAME

b. RANK

Michael Smith

SSgt

c. BRANCH d. DATE OF 3.a. RECIPIENT'S
RELATIONSHIP
OF
DEATH
TO VETERAN
SERVICE
USMC

9/25/1968

Sister

b. RECIPIENT'S FIRST
NAME

c. RECIPIENT'S LAST
NAME

Mary

Smith

ZIP:

ZIP:

N E E D S

ZIP:

ZIP:

D D

6 7

ZIP:

ZIP:

ZIP:

ZIP:

ZIP:

ZIP:

b. TELEPHONE NUMBER

c. ORGANIZATION

d. EVENT DATE

*Requests should be emailed 60 days prior to presentation to:
[email protected]

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